MEDICARE: DEMETRIUS C ZODIATIS,MD.PC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	119465

General Provider Information

NPI Number	:	1558658989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEMETRIUS C ZODIATIS,MD.PC.

Provider Business Mailing Address
First Line	:	1388 STONY BROOK RD
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-2205
Country	:	US
Telephone Number	:	631-751-7588
Fax Number	:	631-689-3665

Provider Business Practice Location Address
First Line	:	1388 STONY BROOK RD
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-2205
Country	:	US
Telephone Number	:	631-751-7588
Fax Number	:	631-689-3665

Authorized Official
Title or Position	:	CEO OF CORPORATION
Name	:	DR. DEMETRIUS CHRISTOS ZODIATIS I
Credential	:	MD,FACP
Telephone Number	:	631-751-7588

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	07/06/2011

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